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State of tAit nt»[,i''!9
County of 1:L4 1t-vtr i
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Affidavit of Survivorship
Dated this 111 day of (y cT, 201
ss.
Subscribed and sworn to before me, a
St�t��y%bytII D. Burns, this day of
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*p4;.••' \:iFAVSslimy hand and official seal.
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w ;COUNTY OF LINCOLN
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Expires: b 1 E J an
I, Harry D. Burns, being of lawful age and duly sworn according to law, upon
my oath, depose and state:
That under the date of June 8, 1979, for valuable consideration, Opal Mercantile,
Co., Inc., a Wyoming corporation, by deed of that date, which deed was duly filed of
record in the Office of the Lincoln County Clerk, on June 14, 1979, in Book 157PR, Page 1,
conveyed to Harry D. Burns and Patricia G. Burns, husband and wife, as tenants by the
entireties, the following described land, in the County of Lincoln, State of Wyoming, to-
wit:
The Lot Numbered Four (4) of the Block Numbered Eight (8) of the
Amended Plat of the Town of Opal, County of Lincoln, State of Wyoming,
as surveyed, platted and recorded in the Office of the Lincoln County
Clerk and Ex- Officio Register of Deeds, together with all improvements
and appurtenances thereon situate or in anywise appertaining thereunto
That by reason of said conveyance aforesaid, the said Harry D. Burns and Patricia
G. Burns, became the owners of said real property, and the title thereto vested in them
continuously from the date of said conveyance, to the date of death of Patricia G. Burns,
also known as Patricia Gail Burns, on the 17th day of September, 2014. That by reason of
and upon the death of Patricia G. Burns, title in the above described real property vested
in Harry D. Burns.
Affiant avers and certifies that Patricia G. Burns, also known as Patricia Gail
Burns, is the identical party named with Harry D. Burns in the aforementioned deed,
whose death terminated her interest, title and estate in said real property; and Affiant
attaches hereto, and makes a part of this affidavit, a copy of the Official Certificate of
Death of said decedent, duly certified by the public authority in which said death
certificate is a matter of record.
4 Lit.
Harry D. Burns
f Aotary public in and for said County and
UGI k'3e-t— 2014.
gam,. oo
Notary Public
l
,ttt, 795893
Decedent:
Name: Patricia Gail Burns
Gender: Female
Date of Birth: June 30, 1951
Date and Place of Death:
Date of Death: September 17, 2014
City of Death: Kemmerer
Location: South Lincoln Medical Center PO Box 390
Additional Decedent Information:
Place of Birth: Leaksville, North Carolina
Residence: Opal, Wyoming
Marital Status: Married Harry Douglas Burns
Armed Forces: No
Name of Father: Phillip Douglas Rawlings
Name of Mother: Peggy June Weadon
Informant: Harry Douglas Burns Relationship: Husband
Disposition:
Method of Disposition: Cremation
Place of Disposition: UFD Cremation Center, South Jordan, Utah
Funeral Home or Facility:
Facility: Ball Family Chapel, Evanston, Wyoming
Cause of Death:
The immediate cause is listed on the first line followed by any underlying causes. Interval:
(a) Congestive Heart Failure Unknown
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CERTIFICATION OF VITAL RECORD
STATE OF WYOMING
Certifier:
Type: Physician
Name: George Krell, M.D.
Address: PO Box 390, Kemmerer, Wyoming, 83101
Date Filed: October 07, 2014
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming.
DATE ISSUED: Wednesday, October 08, 2014
opy is not valid unless prepared on paper with an engraved border.
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
State File Number:
Social Security Number:
Age at the Time of Death:
County of Death: Lincoln
James McBride
Deputy State Registrar
1.
2014- 003115
63 years
Other Significant
Conditions:
Manner of Death: Natural Death Time of Death: 19:00 (Actual)
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